ANALYSIS: How AOV Covered Up the KCMA 7-25-2010 OE

A comparison of various documents shows how FAA HQ officials (at AOV) water down initial investigative reports, to produce whitewashed final reports. In this case, the OE occurred at Camarillo on 7/25/2010, but the FLM (Pruitt) took no action. FAA officials were made aware of the incident in the following weeks, but still did nothing. The GC (Marcotte) was never interviewed until McClure flew down from Seattle and conducted a full set of one-on-one interviews on 6/13/2011. He then sent a timely email with details of his findings, to the head of AOV (Ferrante). Amazingly, in the next six weeks, significant content within McClure’s email was cleaned out, so as not to be included in the final memo closing the matter (by Bebble, dated 8/2/2011).

So, here is the setup. The operational error happened on 7/25/2010, with three FAA personnel aware of it. The local controller was named Nielsen; the Ground Controller was named Marcotte; and, an actual Supervisor (FLM, or Front Line Manager) named Pruitt was also present in the tower cab. All three were interviewed by a visiting investigator named McClure … though, these formal interviews did not happen until eleven months after the actual incident.

Below are posted a brief analysis of the 6/13/2011 interviews produced for each of the three tower positions. It notes two versions: the immediate version, as presented in the 6/14/2011 email sent to FAA’s top safety official, Tony Ferrante, just a day after the three interviews (in a thick yellow box); and, a delayed version showing how the details were changed over the next fifty days, so as to produce an official whitewashed explanation, as presented in Dianne Bebble’s 8/2/2011 email to Ferrante (in a thin teal box).

Ground Controller (GC):

The 8/2/11 memo does not include the key opening statement (“the GC confirmed the loss of separation”) in McClure’s 6/14/11 email to Ferrante, but instead adds two bullets. The removed confirmation statement buries an appearance that, in June 2011, the investigator (McClure) was accepting the fact that there was an LoSS (i.e., a loss of standard separation, thus an error). The two added bullets appear to point at the need for Nielsen to file an ATSAP, and they smooth over the fact that Marcotte was not yet interviewed (in eleven months!). Oddly, the added bullet (#7 in the Bebble memo) about GC advising LC ‘sometime after 7/25/10’ implies it may have been weeks later, yet the ATSAP requirement means the advising had to happen on 7/25/10 or early 7/26/10. This is very deceptive.

…was changed to…

Local Controller (LC):

Bullet #3 within the 6/14/11 email includes an explanation that LC speculated that he cancelled the takeoff clearance “…perhaps it was because the Cessna was still on the runway between taxiways Bravo and Charlie.” It is puzzling that this was removed in the Bebble memo, especially since it fits perfectly with the declared observations by the one witness who did not suffer memory loss (Marcotte). Bullet #4 within the 6/14/11 email to Ferrante was also removed while drafting the Bebble 8/2/11 memo. This removal takes away evidence of Nielsen’s lack of credibility, thus helps Bebble to imply Nielsen is just as credible as Marcotte.

…was changed to…

Front-Line Manager (FLM):

Bullets #2, #3 and #4 within the 6/14/11 email to Ferrante are removed when producing the Bebble 8/2/11 memo. This removal obscures that, during the investigation, a focus was on a serious performance failure by Pruitt, as to his inattention (and even potential worksite absence) about what happened and about compiling a 7210.56 report.

Interestingly, at bullet #4, the McClure email fails to note that FLM had an option to NOT file a 7210.56 report had he himself filed an ATSAP. We know that at least one ATSAP was filed, but we do not know who filed. In any event, even if Pruitt filed an ATSAP, the facility management would still be required to do a full investigation and report data onward, in accordance with Order 7210.56. For this incident, nothing was done.

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